Payment Authorization Form

It is our office policy to require credit card information for each patient. This information is part of your
confidential medical chart.

Why do we need this information?

Yes, we do participate with your health plan!

Yes, we do accept their negotiated fee as payment in full!

However, many plans now subtract deductibles, co pays and coinsurance from this negotiated
fee.
We have no way of knowing what these co pays, deductibles and coinsurance are fully, until
payment is received from your plan. The information provided will ONLY be used for these charges when we receive the explanation of benefits from the insurance carrier. We are not responsible as to how your insurance plan processes the claims. Please request a copy of this form for your records.
If you elect to decline our request for credit card information and we need to bill you, a $25 fee will be charged. We accept Discover, Visa, MasterCard, and
American Express.

FORM MUST BE COMPLETED BY PATIENT

Patient Name*

Chart#*

Address*

Home#*

Work#*

Type of card:*

Visa

MasterCard

Discover

American Expres

Card#*

Exp Date*

Security Code*

If other than patient:

Cardholder Name and Address*

Patient/ Cardholder Signature*

YOU WILL BE ASKED TO FILL THIS FORM OUT AGAIN
ONCE THE CURRENT CARD ON FILE EXPIRES.